How to Complete and Submit the Facility Reported Incident (FRI) Form

The Facility Reported Incident form is how a long-term care facility notifies its state survey agency of an alleged incident of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or an injury of unknown source. File it within two hours if the allegation involves abuse of any kind or results in serious bodily injury, and within 24 hours otherwise. The form itself follows the CMS sample layout in Exhibit 358 of the State Operations Manual, though most states deliver it through their own electronic portal.1Centers for Medicare & Medicaid Services. Exhibit 358 – Sample Form for Facility Reported Incidents Get the classification and timestamps right on the first submission; they drive everything the state does next.

When You Have to File

The reporting obligation is triggered by an allegation, not a confirmed event. A resident, family member, staff member, or anonymous caller can raise the allegation, and the facility does not get to weigh credibility before filing. The FRI goes out first; the investigation follows.2eCFR. 42 CFR 483.12 – Freedom From Abuse, Neglect, and Exploitation

Each triggering category has a specific regulatory meaning, and misclassifying the event on the form can slow the state’s response.

  • Abuse is the deliberate infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. It covers physical, verbal, sexual, and mental abuse, including abuse carried out through technology. The act must be deliberate, but the regulation does not require that the person intended harm.3eCFR. 42 CFR 488.301 – Definitions
  • Neglect is a failure by the facility, its staff, or its service providers to deliver goods and services a resident needs to avoid physical harm, pain, mental anguish, or emotional distress.3eCFR. 42 CFR 488.301 – Definitions
  • Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent.3eCFR. 42 CFR 488.301 – Definitions
  • Mistreatment is inappropriate treatment or exploitation of a resident, a catch-all that picks up conduct not squarely covered by the other definitions.4eCFR. 42 CFR 483.5 – Definitions
  • Injuries of unknown source must also be reported when the cause of an injury cannot be explained.2eCFR. 42 CFR 483.12 – Freedom From Abuse, Neglect, and Exploitation

The Two Reporting Windows

Federal regulations set the deadline based on the nature of the event, not on how long the facility needs to investigate. Reports go to the facility administrator, the state survey agency, and adult protective services where state law gives that agency jurisdiction over long-term care facilities.2eCFR. 42 CFR 483.12 – Freedom From Abuse, Neglect, and Exploitation

  • Two hours from the time the allegation is made, if the events involve abuse of any kind or result in serious bodily injury.
  • 24 hours from the time the allegation is made, if the events do not involve abuse and do not result in serious bodily injury.

CMS defines serious bodily injury as an injury involving extreme physical pain, a substantial risk of death, protracted loss or impairment of a bodily function, or the need for medical intervention such as surgery, hospitalization, or physical rehabilitation. Criminal sexual abuse automatically qualifies regardless of the physical outcome.1Centers for Medicare & Medicaid Services. Exhibit 358 – Sample Form for Facility Reported Incidents

Any allegation involving abuse falls into the two-hour window, even when there is no physical injury. This is where facilities most often stumble. A resident who reports that a staff member screamed at and belittled them is alleging abuse, so the clock runs at two hours, not twenty-four.

The 5-Working-Day Follow-Up

Filing the initial FRI does not close the loop. Within five working days of the incident, the facility must submit the results of its investigation to the administrator (or designee) and to state officials. If the investigation confirms the allegation, corrective action is required.2eCFR. 42 CFR 483.12 – Freedom From Abuse, Neglect, and Exploitation CMS provides a companion document, Exhibit 359, specifically for this follow-up. During the investigation period, the facility must also protect residents from further potential harm by reassigning the alleged perpetrator, increasing supervision, or taking other steps the situation demands.

What to Gather Before You Open the Form

Collecting the raw data before you start keeps the narrative coherent and prevents gaps that invite a request for additional documentation later.

  • Resident identifiers for everyone directly or indirectly involved: full name, date of birth, gender, Medicaid status and number where applicable, and any diagnoses that bear on the incident.
  • Staff identifiers: name, job title, and contact information for the person who discovered the incident, the person who reported it to the administrator, and any witnesses. Note the date and time the administrator was notified.
  • Location details, down to the room number, hallway, or dining area.
  • A chronological timeline: when the incident occurred (or a note that the date or time is unknown), when staff first became aware, and when the initial response ended.
  • Written witness statements, secured while details are fresh.

Flag any prior similar allegation involving the same resident; the form asks. Document whether the resident is still in the facility, and if not, where they are now.

Filling Out the Form

Most states deliver the FRI through an electronic portal run by the state health department. Field labels and interfaces vary, but state versions follow the CMS Exhibit 358 layout closely.1Centers for Medicare & Medicaid Services. Exhibit 358 – Sample Form for Facility Reported Incidents

Facility Identification

The opening section captures the facility’s name, address, administrator name, CMS Certification Number, and contact information. Double-check the CCN. An incorrect number can route the report to the wrong record in the state tracking system.

Incident Classification and Timestamps

Checkboxes let you flag the type of allegation: abuse, neglect, misappropriation of resident property, exploitation, mistreatment, or injury of unknown source. Pick the category that matches the federal definition, and check every one that applies if the event fits more than one.

Below the classification, enter the incident date, time, and location. If the exact date or time is unknown, use the fields provided to say so. Record when staff first became aware of the incident and when the administrator was notified. These timestamps are what the state survey agency uses to decide whether the facility met the two-hour or twenty-four-hour deadline.

Resident and Staff Information

Enter the identifying details you gathered in advance. For each resident, indicate whether they have been involved in a prior similar incident and whether they remain in the facility. For alleged perpetrators who are staff members, record position and employment status.

Narrative

The narrative is the most important part of the form and the section where most problems occur. Describe what happened in chronological order and stick to observable facts: what was seen or heard, by whom, and what the facility did in response. Quote residents when they said something specific. Summarize witness observations plainly.

Avoid conclusions about fault, medical diagnoses you are not qualified to make, and subjective characterizations like “the resident seemed fine.” Regulatory reviewers read dozens of these narratives a week. The ones that trigger follow-up questions have vague timelines (“sometime during the shift”), missing actors (“it was reported that…”), or language that minimizes the event.

Final Review

Confirm that every mandatory field is filled and that the contact information for the facility representative who will handle any follow-up is current. An incomplete form is grounds for the agency to request resubmission, which eats into your reporting window.

Submitting the Form

Completed FRI forms go to the state survey agency. Each state manages its own electronic reporting portal; some also accept submissions by fax or secure email. The state survey agency enters the report into the ASPEN Complaints/Incidents Tracking System (ACTS), the federal database CMS uses to track complaints and incidents across certified providers.

When your submission goes through, you should receive a confirmation number or digital receipt. Keep it. That record is proof the facility met its reporting deadline, and compliance officers should maintain a log of confirmation numbers alongside the corresponding incident files. If you submit by fax or email, retain the transmission confirmation as your timestamp.

The Separate Report to Law Enforcement

The FRI notifies the state survey agency. Filing it does not satisfy a separate obligation to report suspected crimes to law enforcement. Section 1150B of the Social Security Act requires any covered individual (owners, operators, employees, managers, agents, or contractors of a long-term care facility receiving federal funds) to report a reasonable suspicion that a crime has been committed against a resident.5Social Security Administration. Social Security Act 1150B – Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities

The timelines mirror the FRI deadlines: two hours if serious bodily injury is involved, 24 hours if it is not. But the report goes to local law enforcement. Both reports must happen independently within their respective deadlines.

Penalties under Section 1150B are directed at individuals. A covered individual who fails to report faces a civil monetary penalty of up to $200,000. If the failure to report exacerbates harm or leads to harm to another person, the penalty can reach $300,000. The Secretary of Health and Human Services can also exclude the individual from participation in any federal healthcare program. Facilities that retaliate against a person who makes a report face their own penalty of up to $200,000 and can be excluded from federal programs for two years.5Social Security Administration. Social Security Act 1150B – Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities

What Happens After You File

Once the state survey agency receives the FRI, intake staff triage it based on how severe the alleged harm is and how likely it is to recur. CMS scores each deficiency on scope (isolated, pattern, or widespread) and severity (from no actual harm with potential for minimal harm up to immediate jeopardy).6Centers for Medicare & Medicaid Services. Nursing Home Enforcement The score determines how fast the state responds.

Reports that suggest immediate jeopardy prompt an on-site investigation. If the survey team confirms immediate jeopardy, they notify the administrator, provide documentation of the noncompliance, and request a written plan to remove the jeopardy immediately. Lower-severity reports may be folded into the next scheduled survey. The agency may also request additional documentation from the facility during or after the investigation: nursing notes, physician orders, internal investigation files, staffing records, or surveillance footage.

If the investigation reveals deficiencies, the state agency issues a Statement of Deficiencies on CMS Form 2567.7Centers for Medicare & Medicaid Services. Statement of Deficiencies and Plan of Correction (CMS-2567) The facility then has 10 calendar days to submit a Plan of Correction for each cited deficiency, with a target date for when each will be resolved.8Centers for Medicare & Medicaid Services. Quality, Safety and Oversight – Enforcement

Penalties for Getting the FRI Wrong

Failing to report, reporting late, or submitting incomplete reports can trigger enforcement actions well beyond the paperwork itself. CMS and the state survey agency choose remedies based on the scope and severity of the underlying deficiency.

  • Civil monetary penalties for lower-range deficiencies (not constituting immediate jeopardy) run from $136 to $8,211 per day. For upper-range deficiencies, including immediate jeopardy, per-day penalties run from $8,351 to $27,378. Per-instance penalties run from $2,739 to $27,378 regardless of severity category.9Federal Register. Annual Civil Monetary Penalties Inflation Adjustment
  • Denial of payment for new admissions is mandatory if a facility does not return to substantial compliance within three months.6Centers for Medicare & Medicaid Services. Nursing Home Enforcement
  • Termination from Medicare and Medicaid participation is mandatory for a facility that fails to achieve substantial compliance within six months.6Centers for Medicare & Medicaid Services. Nursing Home Enforcement

These remedies are cumulative. A facility facing per-day civil monetary penalties for an immediate jeopardy situation is also running against the three-month and six-month clocks. The FRI is the first document in that chain. Filing it accurately and on time will not guarantee a clean outcome, but filing late or incompletely almost guarantees a worse one.